An Idea Factory for Pathology Informatics and the Clinical Laboratory. Presented by the Pathology Education Consortium (PEC).

404 posts categorized "Medical Education"

In a recent article available on-line on the JAMA Network entitled Adapting to Artificial Intelligence: Radiologists and Pathologists as Information Specialists (see: Radiologists and Pathologists as Information Specialists), the authors Saurabh Jha and Eric Topol conclude that both pathologists and radiologists function as "information specialists" and therefore should consider merging their specialities. Below is an excerpt from the article:

Radiologists are more aptly considered “information specialists” specializing in medical imaging. This is similar to pathologists, who are also information specialists.Pathologists and radiologists are fundamentally similar because both extract medical information from images. Pathologists have embraced machines and technologies. Some tasks once performed manually by pathologists have been automated, such as cell counts, typing and screening of blood, and Papanicolaou tests, leaving pathologists with more complex tasks. Artificial intelligence can perform the more complex tasks of pathologists and, in some instances, with superior accuracy....Because pathology and radiology have a similar past and a common destiny, perhaps these specialties should be merged into a single entity, the “information specialist,” whose responsibility will not be so much to extract information from images and histology but to manage the information extracted by artificial intelligence in the clinical context of the patient. The information specialist would not spend time inferring conditions between competing shadows on radiographs, scroll through hundreds of images looking for pulmonary embolus on CT, or examine slides for “orphan Annie”–shaped nuclei. Artificial intelligence could perform many such tasks. The information specialist would interpret the important data, advise on the added value of another diagnostic test, such as the need for additional imaging, anatomical pathology, or a laboratory test, and integrate information to guide clinicians. Radiologists and pathologists will still be the physician’s physician. Together, the information specialist and artificial intelligence could manage individuals and populations.

R. Nick Bryan, M.D. is the new director of diagnostics for the Dell Medical School at The University of Texas at Austin. He will oversee diagnostic activities for Dell Medical School, encompassing the traditional departments of radiology, pathology and laboratory medicine. Doing so will merge key components of diagnostic examinations that determine the health status of patients. Dell Med’s innovative approach will help ensure that these skills are taught and used in a more integrated way.

I suspect that if you were to ask most pathologists and radiologists to specify their primary professional task, the majority would probably choose the diagnosis of disease ratherthan the management of diagnostic information. One exception to this rule would be clinical pathologists who generally do not personally create most of the information from the clinical labs. The raison d'être of surgical pathologists and radiologists has thus always been the interpretation of images. Jha and Topol, however, suggest that we are now at a critical inflection point in both surgical pathology and radiology. Artificial intelligence (AI), image recognition software, and deep learning using big data (see: Allscripts Launches a Subsidiary, 2bPrecise, Focusing on Genomic Testing) have taken us to the point where most diagnostic reports will soon be generated by computers.

As an increasing number of reports are created by computers, pathologists and radiologists will begin to serve primarily as managers of information and must decide exactly which cases require human, professional intervention and interpretation. Most of us tend to view our careers and our medical specialties through the rear view mirror. More than a decade of discussion about the role of pathologists and radiologists in this information era should be sufficient to prompt a more serious discussion of what the future holds in store for medical diagnosticians. I personally believe that it lies in the creation of Departments of Diagnostic Medicine.

Routine telemedicine visits at the present time are usually restricted to low-intensity patients with the exception of telemedicine as it relates to "remote ICUs" (see: Remote ICUs). Here is a description of remote ICUs from this article:

Telemedicine is most commonly used in one-on-one scenarios between a physician and a patient or between two physicians. Increasingly, however, remote ICU’s are being implemented to help extend the range of intensivists, as well as allow them to monitor multiple patients in multiple facilities. By utilizing advanced medical imaging, video conferencing, and computer software technology, specialists can effectively monitor a larger group of intensive care patients, and consult with on-site nurses and physicians when hands-on care becomes necessary. Remote ICUs have resulted in a number of positive outcomes, including decreased patient mortality, shorter ICU stays, and rapid return on investment for hospitals.

Because the technology has existed for years for sophisticated remote monitoring of critical care patients, I am convinced that it is only a matter of time before it becomes cost-effective to assess vital signs and more during "routine" patient televisits. I use the word routine here to indicate that the range of ambulatory patients who can be served by telemedicine is about to greatly expand. A recent article discussed how American Well, a major vendor of telemedicine software, is incorporating remote examination tools in collaboration with TytoCare (see: American Well taps TytoCare to incorporate connected health tools into video visits). Below is an excerpt from this article:

Telemedicine provider American Well has teamed up with Israel-based medical device maker TytoCare to combine video telehealth visits with remote examinations. With the partnership, TytoCare’s examination platform will be integrated into American Well’s telehealth platform. In turn, TytoCare’s customers will have access to the network of healthcare providers who use American Well’s platform. Patients will be able to replicate an in-office visit at home by using TytoCare’s platform to examine the skin, heart, lungs, abdomen, ears, throat and skin. Then, they can share the examination with a clinician prior to or during a telemedicine visit. TytoCare, which recently received FDA clearance for its digital stethoscope, offers several FDA Class 1 devices: a connected otoscope for ear examinations, a high-resolution camera, and a thermometer that is placed on the forehead for a reading. The devices pair with smartphones to capture, store and share data via a cloud-based telehealth platform with video conferencing...."Our partnership with Tyto Care arms remote telehealth physicians with the physical examination they traditionally needed to safely diagnose, treat and follow medical conditions while the patient remains in their home,” American Well CEO Dr. Roy Schoenberg said in a statement.

There will obviously be significant patient training necessary for the TytoCare kit to be used to record heart sounds and murmurs, uploading them to the cloud, and then making them available during a telemedicine visit by a physician. Much sooner, however, will be the use of such technology using the product called TytoClinic. Increasingly, nurse practitioners (NPs) are working independently in their own practices (see: What's an NP?). I envision NPs providing independent services to a wide range of patients as part of large health systems. When they encounter patients with problems beyond their expertise, they can use such TytoClinic kits, combined with the American Well software, to consult with a physician. Such a workflow will enable health systems to serve far more patients and also triage those with the more serious problems.

The University of Michigan Health System has established a new partnership with Meijer pharmacies to provide hypertension management services for adult patients. U-M patients will be able to visit participating Meijer pharmacy locations to receive a blood pressure check and assessment. If the patient’s blood pressure is elevated, the clinically trained Meijer pharmacist will communicate directly with the patient’s U-M Health System provider. The patient will also receive appropriate follow-up and education about disease, clinical goals, medications and lifestyle. In addition, documentation of the patient’s visit to their Meijer pharmacy will be recorded in their electronic medical record so the patient can easily discuss the reading and assessment with their U-M Health System provider at their next medical visit.....Each participating Meijer location has purchased an automatic blood pressure monitor to provide more accurate readings to patients. The device takes six consecutive blood pressure readings and provides an average of the readings....U-M Health System patients with elevated blood pressure will be identified at clinic visits and given the option to visit the Meijer pharmacy for their follow-up care.

It's interesting that the automated blood pressure devices used in this program acquire six consecutive readings and then provide an average of these readings. It would be interesting to study whether blood pressure recordings taken by a pharmacist with automated devices are subject to the so-called "white coat syndrome" in which readings are falsely elevated during a clinic visit because of patient nervousness (see: Beyond 'White Coat Syndrome'). If patients don't have too high blood pressures when interacting with a pharmacist, the name of the syndrome may need to be changed since many pharmacists wear white coats.

For me personally, the noxious habit of smoking does not seem to exist any more. At home and when traveling to large cities in the U.S., I rarely see anyone smoking. And yet, here's an article that indicates that smoking is linked to one-fourth of all U.S. cancer deaths (see: One-fourth of US cancer deaths linked with 1 thing: smoking). Below is an excerpt from it:

Cigarettes contribute to more than 1 in 4 cancer deaths in the U.S. The rate is highest among men in Southern states where smoking is more common and the rules against it are not as strict. The American Cancer Society study found the highest rate among men in Arkansas, where 40 percent of cancer deaths were linked to cigarette smoking. Kentucky had the highest rate among women - 29 percent.The lowest rates were in Utah, where 22 percent of cancer deaths in men and 11 percent in women were linked with smoking....Lung, throat, stomach, liver, colon, pancreas and kidney cancers were among those included, along with leukemia. The researchers estimated how many cancer deaths were likely attributable to smoking, and compared that with deaths from all cancers. While U.S. smoking rates have been falling, 40 million U.S. adults are cigarette smokers and smoking is the top cause of preventable deaths, according to the [CDC]. The study found that at least 167,000 cancer deaths in 2014 - about 29 percent of all U.S. cancer deaths - were attributable to smoking. A government estimate based on different methods says 1 in 3 U.S. cancer deaths are linked with smoking, and the study authors acknowledge they may have underestimated the true burden posed by cigarettes. Most of the 10 states with the highest rates of smoking-attributable cancer deaths were in the South, while most of the 10 states with the lowest rates were in the North or West....The average cigarette excise tax in major tobacco states, mostly in the South, is 49 cents, compared with $1.80 elsewhere. The tobacco industry heavily influences these policies and most of the U.S. tobacco crop is grown in the South....

Note that cigarette smoking is associated with many cancers in addition to the lungs: throat, stomach, liver, colon, pancreas and kidney. For example and on average, smokers have a 50% increase in risk of kidney cancer. Smokers also have up to three times the risk of developing cancer of the renal pelvis compared to non smokers (see: Risks and causes of kidney cancer). There are some 70 known carcinogens in tobacco smoke and some of them are undoubtedly concentrated in the urine as the cause of these cancers (see: Carcinogens in Tobacco ProductsTobacco smoke).

Clearly, smoking is an essential component of the economy of the southern U.S. states and also an important part of the culture. States, not just people, can become addicted to tobacco. "Tobacco production is an important industry in Kentucky, which along with North Carolina generates two-thirds of the nation's tobacco harvest....People aren't necessarily more likely to smoke if they live in a tobacco-growing state, but Kentuckians are certainly doing their part to help the local economy. The state has the nation's second-highest adult smoking rate, as well the highest rate of smoking-related deaths. Most alarming of all, Kentucky is encouraging more smokers: The smoking rate among high schoolers is the highest in the U.S." (see: The 10 States Most Addicted to Smoking). So unless and until the South is able to wean itself off tobacco production as well as increase the taxes it imposed on cigarettes, I suspect that the cancer rate and health costs associated with this addiction will continue at high levels compared to the rest of the country.

One of the major changes we will soon see to improve healthcare delivery is physicians prescribing apps for their patients. Particularly for patients with chronic conditions like diabetes and obesity, it's imperative that patient education be improved. Unfortunately, physicians and nurses can't stand beside patients continuously to help with their disease management. Here's where smart phone apps will come into play. Mount Sinai Health System working with the Icahn School of Medicine has developed RxUniverse, an enterprise-wide platform of curated apps that allows physicians to prescribe them directly for their patients (see: Mount Sinai launches RxUniverse, a system-wide platform to prescribe medical apps). Below is an excerpt from this article:

The platform... aims to address the lack of standardized methodology for physicians to both ascertain which apps would best benefit their patients, and subsequently share with them directly....RxUniverse allows physicians and other healthcare providers to seamlessly and confidently integrate evidence-based digital health tools into their practice. RxUniverse integrates as a feature to the patient’s EHR, and once clinicians open the patient’s electronic file, they can click on the RxUniverse function to digitally prescribe an app through a link that is sent to the patient’s smartphone. The platform also features specifically tailored educational content, patient satisfaction surveys and other digitally-prescribed tools. As the pace of innovation in digital medicine accelerates, there will be increasing demand for the ability to quickly integrate new apps into our health care system....The RxUniverse platform was piloted this summer at five clinical areas at Mount Sinai with the goal of prescribing 100 apps. Since then, participating clinicians have prescribed more than 2,000 apps.

Las Vegas-based digital health enabler SocialWellth today announced the acquisition of Happtique, creators of the first provider-led app prescribing software. Happtique was founded and wholly owned by GNYHA Ventures, the business arm of the Greater New York Hospital Association. The acquisition complements SocialWellth’s existing digital health offerings for healthcare sponsors by enabling them to be connected not only to their members, but also to providers, encompassing the total continuum of care....“We believe that the digital health market must shift from passive digital health to prescriptive digital health curation if we are to achieve the great potential which lies ahead with Connected Patients,”...[a spokesperson] added.

Regarding the health data generated by "wearables" and home mini-labs (i.e., labs-on-a-chip), I had always assumed it would be uploaded to the cloud or web sites and then monitored by physicians and nurses (see: 10 Healthcare Wearables, Devices Dominating CES). Although I expect this to still take place, I now understand that most of the monitoring will be via health apps running on the patients' own smart phones. Moreover and as emphasized in the excerpt at the top of this note, prescribed apps will also be synchronized with "tailored educational content" such as training videos. For example, if a patient with diabetes has questions about diet, he or she can directed to relevant videos on his or her cell phone.

We are now in a stage of digital medicine when we are able to study various digital processes to tease out both their advantages and disadvantages. One major focus in the future will certainly be assessing the effectiveness of telemedicine physician visits. A recent article about e-prescriptions caught my attention (see: Electronic Prescribing Tied to Higher Adherence). Below is an excerpt from it:

Electronic prescribing (e-prescribing) decreases prescription errors and enhances coordination between physician and pharmacist, but what has remained unclear is how it affects patient behavior. Now a new study suggests e-prescribing may enhance patient prescription adherence. In an analysis of nearly 2500 patients, e-prescribing was associated with a significant reduction in primary nonadherence, defined as not filling and picking up all prescriptions within 1 year of the prescription date. The researchers compared rates of nonadherence associated with e-prescriptions and paper prescriptions among new patients attending an outpatient dermatology clinic at a large urban hospital.The risk for primary nonadherence was 17 percentage points lower with e-prescriptions than that associated with paper prescriptions, for a 16% difference after adjusted multivariable analysis....This "represents a 47% reduction in the risk of primary nonadherence for patients who received an e-prescription vs those who received a paper prescription.

It's interesting to speculate why nonadherence would be much lower with e-prescriptions than with paper prescriptions. I am only guessing, but this may be a case of digital literacy at play. The term is defined in the following way:

Digital literacy is the knowledge, skills, and behaviors used in a broad range of digital devices such as smartphones, tablets, laptops and desktop PCs, all of which are seen as network rather than computing devices. Digital literacy initially focused on digital skills and stand-alone computers, but the focus has moved from stand-alone to network devices....Computer literacy preceded digital literacy, and refers to knowledge and skills in using traditional computers (such as desktop PCs and laptops) with a focus on practical skills in using software application packages. Digital skills is more contemporary term but is limited to practical abilities in using digital devices (such as laptops and smartphones).

Clearly, digital literacy is linked to socioeconomic status and education, with those higher on the scale being more familiar and comfortable with digital devices and computer networks. A patient with a lower level of digital literacy might not always understand that his or her prescription is being transmitted electronically to a local drug store for filling and that the process is reliable. In contrast, carrying a paper prescription to the store would be a familiar task. It's also possible that some of the patients receiving e-prescriptions did not fill them (primary nonadherence) because they could not afford to pay for them but this effect should have been the same in both study groups. If there is a lesson here, it's that physicians providing e-prescriptions for patients should not take for granted that the patient understands how the process works and is reliable.

For more than a decade, Dr. Mike Laposata, pathology chairman at UTMB Health in Galveston, has been pioneering the concept of diagnostic management teams (DMTs) whereby pathologists and lab professionals, engage with their clinician colleagues to help diagnose patients, particularly those with complex medical problems. A recently announced conference on February 7-8, 2017, will provide more details about this new facet of the practice of pathology. Below are some details from an email that I received today from Dr. Laposata:

This inaugural Diagnostic Management Team Conference will have historical significance as we change the way we, as laboratory leaders and pathologists, assist healthcare providers on diagnostic test selection and results interpretation. The National Academy of Medicine report from 2015, Improving Diagnosis in Health Care, endorsed the formation of diagnostic management teams to address the major problem of diagnostic error that affects the lives of hundreds of thousands of individuals every year. Take a look at the program and meeting web site, imagine your new capabilities, and join us on February 7 and 8, 2017 in Galveston, Texas at the Galveston Island Convention Center....Now is the time to establish the true value of the laboratory and the crucial work we all do for patients. will have historical significance as we change the way we, as laboratory leaders and pathologists, assist healthcare providers on diagnostic test selection and results interpretation.

When physicians fail to order the correct laboratory tests or incorrectly interpret the test results, even when a lethal outcome ensues, the poor outcome is rarely attributed to the doctor’s mistake involving the laboratory tests. Even as the clinical laboratory test menu has enlarged in cost and complexity, laboratory directors do not routinely provide patient-specific, expert-driven narratives of complex clinical laboratory evaluations....The ordering physicians live in a world with thousands of tests, many new and highly expensive, where we call the same test by multiple different names in different laboratories. For example, there are at least 5 different names and 5 different abbreviations for von Willebrand factor activity, and there are at least a dozen tests with the word vitamin D in the title presented to physicians who simply want to know of their patient is vitamin D deficient. The consequence is that doctors order unnecessary tests and often fail to order tests which can provide an immediate and conclusive diagnosis.

This is a conference you don't want to miss. Improving the interpretation of lab tests will go a long way toward eliminating diagnostic errors. We owe it to Dr. Laposata and also to ourselves to support all of his efforts. You can register at the conference web site.

We are on the cusp of a broad roll-out of various types of "e-presence" programs in hospitals. Just to get on the same page, here's a definition for e-presence: The act of being "live" online. Whether in an IM exchange, or video, or even email. ePresence is that quality of feeling that the entity at the other end of the exchange is actually there and responding (see: e-presence). I think that one of the common denominators of e-medical video applications is that providers and patients are interacting on a live basis. These e-presence programs and apps will range from relatively low complexity ambulatory visits (see: Details of Cleveland Clinic's MyCare Online Virtual Telemedicine Visits) to telepsychiatry visits (see: Telepsychiatry) to virtual ICU's care in small hospitals from specialists in larger ones (see: Anatomy of a virtual ICU: Study probes teamwork among on-site, remote staff).

The reasons for my optimism about the rapid growth of e-presence initiatives is that they offer the most cost-effective way to deliver medical services to the growing number of health care consumers. The major expenditures for live on-line services involve networks, software to mange the provider/patient interactions, and the cost of retraining healthcare professionals to use this technology. These costs substitute for bricks-and-mortar costs which will always be substantially more and lack the flexibility of e-presence programs. Patients, of course, need their own devices in their homes but many will already own smart phones or tablets. I fully understand that there questions remain regarding telemedicine reimbursement (see: Telemedicine Reimbursement), but I fully expect them to get ironed out quickly.

As these e-presence initiatives emerge within individual health systems, there will be a need to blend them under some type of organizational structure within health systems because the technical infrastructure will be similar or the same for most of them. For example and for most of these initiatives, one common need will be to order lab tests and to view test results so that they are visible to patients and the physicians delivering services. This note is intended, in part, for my pathology informatics colleagues, suggesting that they take the initiative in developing the technical infrastructure, processes, and organization structures for their own hospital e-presence programs.

Individuals with jobs in farming, fishing, and forestry have the highest suicide rates, followed by those working in construction, according to an analysis by the US Centers for Disease Control and Prevention (CDC). In 2012, suicide was the 10th leading cause of death in the United States, with roughly 40,000 deaths by suicide reported....From 2000 to 2012, rates of suicide jumped 21%, from 13.3 to 16.1 per 100,000....Suicide rates may be high in these occupations for a number of reasons, including job-related isolation, stressful work environments, and work-life imbalance....In addition, farmers' long-term exposure to pesticides may affect the neurologic system and contribute to depressive symptoms. Workers in installation, maintenance, and repair jobs may also have long-term exposure to neurotoxic solvents. Overall, the lowest suicide rate ― 7.5 per 100,000 ― was among education, training, and library workers. The findings, the investigators note, suggest that men working in farming, fishing, and forestry occupations and women working in protective services occupations may benefit from targeted suicide prevention efforts.They point out that evidence-based suicide prevention strategies implemented in the workplace have the potential to reduce the number of suicides among all occupational groups. On that front, the National Action Alliance for Suicide Prevention (NAASP) Workplace Task Force has developed the Comprehensive Blueprint for Workplace Suicide Prevention, which addresses suicide prevention strategies, such as screening, mental health services and resources, suicide prevention training, life skills and social network promotion, and education and advocacy.

Suicide takes life without regard to age, income, education, social standing, race, or gender. Overall, suicide is the 10th leading cause of death for all Americans, the 2nd leading cause of death for adults ages 25-34, and the 3rd leading cause of death for youth ages 15-24. The legacy of suicide continues long after the death, impacting bereaved loved ones and communities. Fortunately, there is strong evidence that a comprehensive public health approach is effective in reducing suicide rates. In fact, suicide rates have been declining among both American youth and elders for well over a decade, two groups on which the nation has focused most. There are other population groups, though, for which the death toll is rising.

It's worth the time to focus on the three major causal factors in suicide noted above: (1) job-related isolation, (2) stressful work environments, and (3) work-life imbalance. All three are certainly common in farming, fishing, and forestry as well as in the military. However, I think that it would be difficult to implement suicide prevention strategies broadly in these industries. They often involve the work of small companies or individuals with thin profit margins and thus not always amenable to public health initiatives. This whole topic needs more attention.

I am a great fan of telemedicine. There are many kinks that need to be worked out in the deployment of large-scale telemedicine systems. However, this will be the most important response to the need to deliver quality healthcare on a much larger scale. One aspect of this shift in healthcare is the development of a new vocabulary to describe various aspects of patient-provider interactions on the web. A recent article addressed one of these jargon issues (see: At the 'webside'):

When Kaiser Permanente's emergency room wait times began rising three years ago, Dr. Dennis Truing and a colleague launched a telemedicine program to provide faster access to care for their patients (see: Innovations: Kaiser tests video visits to cut waits). At the time, there weren't many training programs for telemedicine or for developing good “webside” manner, which can greatly improve patients' adherence to treatment. Instead, Truing had to learn on the fly....Like its cousin “bedside manner,” webside manner is a key skill for clinicians involved in telemedicine, experts say. Physicians must proffer an empathetic and compassionate presence to calm fears and provide hope for patients who may be suffering from serious or even not-so-serious illness...[B]edside manner can have a statistically significant impact on patient health, affecting the incidence of obesity, asthma, diabetes, hypertension and osteoarthritis. It can also affect weight loss or blood sugar levels in patients. But clinicians are going to have to rethink how they deliver this important element of their craft as medicine moves deeper into the digital age....Approximately 71% of employers say they will offer telemedicine consults through their health plans by 2017. Investment is growing too; the telemedicine market was worth about $500 million in 2014, but that is expected to balloon to $13 billion in 2020....That's why experts and consultants are encouraging physicians to prepare for virtual visits with appropriate equipment and a well-developed “webside manner,” which includes all the same skills as bedside manner but has a number of its own requirements. Just like during a traditional office visit, clinicians must juggle paying attention to the patient with filling out electronic health records and other forms. It's as important to put patients at ease in a virtual environment as it is in an office.

One of the current major barriers to the establishment of telemedicine programs is the training of physicians and nurses to be comfortable with patient interactions at a distance. There's not a lot of accumulated experience about this topic currently. Farsighted hospital executives understand that one of the fastest ways to gain telemedicine experience is to launch a program and learn by doing. I have only quoted a portion of the article cited above so link to it for more information. It's worth the effort.

One fact is obvious to me, however, about telemedicine. Younger physicians and nurses will probably develop their webside skills faster and better than some of the older members of this group. The former are more accustomed to placing video calls using apps like FaceTime and social media. However, I think that it would also be unrealistic to assume that a physician or nurse who has not cultivated good "bedside manners" can subsequently develop good "webside manners." These are a usually a matter of core personality with the added burden of needing to reach out to a patient with only "screen" contact.